Soldiers who participate in combat are at risk of both acute and chronic posttraumatic stress disorder (PTSD) (1), as are victims of terrorist activities, civilian disasters, torture, and rape. Disaster workers are also at risk (2,3). The results of two empirical investigations of emergency services personnel who participated in an earthquake rescue effort suggested that about 9 percent of the workers showed psychological symptoms at the same level as an outpatient population diagnosed as having PTSD (4,5). A study of body handlers found that 11 percent of them had symptoms of PTSD three months after the disaster work (6). Troops deployed in Operation Desert Storm who performed grave-registration duties had more severe symptoms of PTSD than soldiers who did not perform such duties, and nearly 50 percent had current PTSD (7).
Prevention strategies for diseases in general and mental disorders in particular appear to be more efficient than treating an illness in its full-blown stage. Treatment strategies for PTSD are still unsatisfactory (8,9); therefore the development of successful prevention strategies may be of great importance in minimizing the risk of PTSD and in treating anxiety and the affective conditions related to exposure to traumatic events. Attempts to develop successful preventive strategies during the past decade have led to greater interest in the efficacy of strategies such as debriefing.
The Oxford Advanced Dictionary defines debriefing as "questioning or examining, for example of persons who have returned from a mission, in order to obtain information." The term "psychological debriefing" suggests a crisis intervention designed to relieve and prevent event-related distress in normal people who are experiencing abnormally stressful circumstances (10,11,12). The aim of psychological debriefing is to prevent the development of permanent emotional injury by enabling cognitive appraisal and emotional processing of the traumatic experience.
This paper reviews the history of psychological debriefing and evaluates the findings of previous research. Our goals are to increase awareness of this strategy among physicians and mental health professionals and to provide suggestions for further research and implementation of debriefing programs.
S.L.A. Marshall, chief combat historian of the U.S. armed forces during the Second World War, was the first to practice "debriefing," although not as a form of psychological intervention (13,14). Rather, the goal was to explore the "historical truth" by obtaining comprehensive descriptions of combat events from all the survivors in a warm and supportive atmosphere. The sessions were conducted with small groups of soldiers immediately after combat and in the presence of an interviewing officer. The soldiers talked with each other about their experiences and their immediate reactions. Soldiers who had shared the same combat situation often found that they had experienced the same events in very different ways. An advantage of this type of debriefing is that it focuses on actual facts and firsthand accounts.
Marshall's debriefing method consisted of a cognitive review of the events, without any attempt to address their psychological impact (15). Debriefing was described as beneficial for the soldiers because they were able to share their experiences, and group unity was reestablished.
During the Korean and Vietnam Wars, psychologists and psychiatrists further developed the concept and methods of group stress debriefing (15). Military psychiatrists went on to develop immediate, frontline interventions to provide soldiers with short-term assistance and enable them to return to active service (16). These interventions were based on the belief that talking through traumatic experiences aids psychological recovery.
Group debriefing and critical incident stress debriefing strategies have acquired many followers (11,17). The debriefing model developed by Mitchell (11) has been modified and expanded by researchers such as Dyregov (18), who coined the term "psychological debriefing," and Armstrong and colleagues (12), whose multiple stressor debriefing model incorporates an additional coping strategy component specifically designed for disaster relief personnel who face multiple stressors over an extended period of relief operations.
During the past two decades, psychological debriefing has been used with emergency workers, such as paramedics, police officers, and firefighters (11), as well as with disaster workers, hostages, prisoners of war, and soldiers (14,19).
Debriefing relies on three therapeutic components: ventilation in a context of group support, normalization of responses, and education about postevent psychological reactions. The technique consists of reviewing the traumatic experience, encouraging emotional expression, and promoting cognitive processing of the experience.
Treatment usually consists of a single extended group session that begins with a brief description of its purpose. The participants are invited to share their experiences of the traumatic event, starting with describing where they were when they first heard about it and proceeding with subsequent experiences. The session facilitator invites participants to describe the experience in its cognitive, affective, and behavioral contexts. A description of the event's most terrifying moments is also invited. The facilitator acknowledges the intensity of the experience while emphasizing the universality of reactions and reframing perceived failure as something to be expected in a disaster. Advice may be provided about emotional reactions that might be expected, the value of sharing the experience, and the importance of resuming activities fairly quickly in order to minimize phobic avoidance. After the group session, participants may attend a lecture on postdisaster recovery that provides information on common reactions to disaster and phases of recovery.
Psychological debriefing has been used with individuals as well as with groups. The group setting is considered to be the preferred strategy, not only for its economical and technical advantages but also because it recreates a "maternal environment" (15). The group becomes a place to communicate and to reestablish order, trust, and a feeling of safety.
The results of studies of psychological debriefing have been equivocal. Some findings suggest high levels of client satisfaction (20,21). Others have found no difference in psychometric measures between groups that did and did not receive psychological debriefing (22,23). Although debriefing has been widely used after traumatic events, few randomized controlled trials of debriefing have been reported (24). The lack of adequate control groups makes it difficult to judge the efficacy of this type of intervention. Other methodological limitations of published studies include small sample sizes, lack of prospective design, difficulty in controlling confounding variables, low response rates, sampling bias, lack of uniformity in session format and timing, and variation between results obtained from questionnaires and from interviews (25).
Several studies in which participation in debriefing and nondebriefing groups was not randomly determined have examined long-term levels of stress following trauma. McFarlane (26) found that psychological debriefing was generally not predictive of long-lasting posttraumatic stress among 315 firefighters who fought the 1983 Ash Wednesday bush fire in Australia. His findings indicated that although psychological debriefing was associated with a lower level of acute posttraumatic stress, it was associated with a higher level of delayed posttraumatic stress symptoms.
Griffiths and Watts (22) examined relationships between stress debriefing and stress symptoms among 288 emergency personnel involved in traffic accident rescue. Personnel who attended debriefing sessions had significantly higher levels of symptoms at 12 months, as measured by the Impact of Event Scale (IES), than those who did not attend. Furthermore, no relationship was found between the perceived helpfulness of psychological debriefing and the appearance of symptoms. However, personnel who experienced greater distress at the time of the rescue event were likely to have attended more psychological debriefing sessions and to have perceived the sessions as more helpful.
Kenardy and colleagues (27) reported a lack of efficacy of psychological debriefing in a group of 195 helpers involved in earthquake relief work. The subjects of the study were assessed on four occasions, which took place over the two years following the event. The results of the study indicated that the debriefed subjects (N=62) rated the value of the debriefing positively and that they had a rate of improvement similar to that of helpers who were not debriefed, even after the analysis controlled for level of exposure and helping-related stress. The groups differed in demographic and occupational characteristics, however, which could have caused a bias in the results.
Other studies with smaller samples have found similar results. Amir and colleagues (28) reported the effects of debriefing and short-term group psychotherapy among 15 Israeli women who had been the target of a terrorist attack but who had not been injured. The intervention, which began two days after the event, did not provide the women with any substantial relief from suffering. An interesting finding of the study was the association between the appearance of phobic anxiety and later distress, which suggests that debriefing should focus on quick reexposure to nontraumatic aspects of the event and on supportive networks for the victims who are most fearful.
After a catastrophic natural disaster in Hawaii, Chemtob and colleagues (10) evaluated whether brief psychological intervention consisting of debriefing six to nine months after the disaster reduced disaster-related psychological distress, as measured by the IES. The sample (N=43) was composed of mental health workers and persons who were hired to provide community outreach as peer counselors and who had themselves experienced considerable distress and property loss. The participants' IES scores were significantly lower after the intervention than before it. The authors concluded that debriefing is an effective postdisaster psychological intervention.
This study is one of the few in which intervention was delivered relatively late, and it had several limitations. First, only the IES was used; other outcome data, such as data on depression, anxiety, and substance abuse, were not considered. Second, the debriefing was performed six to nine months after the event, so intervening variables could have contributed to the differences in scores. Third, the results are not generalizable because the study included individuals who worked in the mental health field and were knowledgeable about such interventions and knew how to draw psychological benefits from them.
Hobbs and colleagues (24) reported the efficacy of psychological debriefing for victims of traffic accidents in a randomized controlled trial. Intervention occurred 24 to 48 hours after the accidents. Participants in both the intervention group (N=54) and the control group (N=52) showed no significant reduction in specific posttraumatic symptoms, mood, or anxiety symptoms, and the intervention group actually had worse outcomes on two subscales of the symptom inventory. Although group assignment was random, participants who were debriefed had higher injury severity scores and longer hospital stays. These factors in themselves may have resulted in worse outcomes. Furthermore, the study excluded victims who did not have initial psychological symptoms and those who could not remember the accident. Other victims were excluded because they had been discharged or were not available to participate in the study. These exclusions may have caused significant bias.
Deahl and colleagues (23) investigated psychological morbidity among 74 British soldiers who worked with the dead during the Gulf War. For operational reasons, only some of the soldiers were debriefed. Nine months after the event, psychological symptoms of 62 soldiers were assessed with the IES and the General Health Questionnaire. The soldiers who had been debriefed (N=42) did not have lower levels of morbidity than those who had not been debriefed.
Psychological debriefing can be voluntary or enforced. Beyond the general problems associated with psychological debriefing, the practice of enforced debriefing may result in passive participation and resentment. Observation of these outcomes by Flannery and colleagues (29) led them to argue against mandatory debriefing. A good example of enforced early intervention is the case of the Americans held hostage in Iran in the late 1970s. Rahe and colleagues (30) reported that many of the hostages felt ready to fly home immediately after their release, but they were required to undergo a four-day period of seclusion, with a gradual reintroduction to freedom in Germany before being reunited with their families. Most of the hostages acknowledged that their initial feelings had been "overly optimistic"; however, the authors did not comment on the feelings of those who were forced to undergo the debriefing process against their will. Compulsory psychological debriefing may result in a normal emotional reaction being given a medical diagnosis, and it may even produce a secondary trauma (31).
In an uncontrolled, open-outcome study of 34 subjects with PTSD, Busutill and colleagues (32) found that incorporating psychological debriefing into treatment had a marked beneficial effect; however, after one year, about 15 percent of the patients still met criteria for PTSD. Deahl and colleagues (23) have suggested that psychological debriefing might even increase subsequent morbidity. These conflicting findings indicate that more research is required to establish the efficacy of debriefing in the treatment of PTSD, and health care professionals should exercise caution in its use.
Psychological intervention after trauma appears to meet some real and symbolic needs for the victims, helping them to overcome their sense of helplessness and guilt about surviving as well as other overwhelming emotions. Psychological debriefing may answer the need of mental health workers to make an immediate response to suffering (33) and help revive a sense of omnipotence in mental health professionals. It also satisfies the social ideology of immediate public commitment to victims of disaster and violence (21). However, the history of medicine offers a great many examples of ideologies that gained general acceptance in the absence of proper scientific evaluation of their validity, efficacy, or safety. In view of the research to date, psychological debriefing may fall into this category. Therefore an examination of its efficacy in controlled trials is essential.
As currently practiced, psychological debriefing takes into account only the single element of trauma. However, it is possible that other variables, such as the victim's coping processes and defensive styles, previous trauma, and history of psychological morbidity, as well as dissociative phenomena related to the traumatic experience, should be taken into consideration. Furthermore, loss, separation, and dislocation may be separate stressors that call for different interventions and timing (33).
Immediacy has been thought to enhance the efficacy of psychological debriefing, in accordance with the notion that the earlier the debriefing takes place, the less the opportunity for maladaptive and disruptive cognitive and behavioral patterns to become established (34). However, there is no scientific evidence to support this notion. In fact, it is possible that early intervention disrupts defenses and coping strategies, whereas late intervention has the advantage of providing psychological aid when these mechanisms are stronger (17,33). At least one study has found that late rather than early intervention might be beneficial for victims (10). It may be that presenting victims with psychologically traumatic material without allowing sufficient time for the habituation of anxiety produces a flooding effect, resulting in a secondary traumatic experience for some victims. However, this effect may be masked in group studies.
A number of issues should be addressed in further evaluation of the benefits of psychological debriefing, some of which have been discussed by Bisson and Deahl (25). One question for further study is whether there are any critical factors that contribute to effective psychological debriefing. Because psychological debriefing includes components of social support, emotional sharing, cognitive reappraisal, and education, these factors should be evaluated separately and in combination for their relative therapeutic value. Another research question has to do with the target subjects. Is psychological debriefing appropriate for all individuals who have experienced trauma, or is it beneficial only for specific subgroups, such as high-risk individuals? Finally, the most effective format needs to be determined—for example, group sessions versus individual debriefing.
Although psychological debriefing is a popular intervention for disaster workers and victims of traumatic events, not enough clinical data are available to ascertain its effectiveness in preventing posttraumatic morbidity. Much more research is needed to establish its efficacy and to determine the most appropriate format.
Obtaining assessment and follow-up data may be a first step in evaluating efficacy. Assignment of individuals to a matched control group is difficult because of technical and ethical issues, but it may be a necessary step. Research efforts are worth pursuing, however, because if psychological debriefing is found to be effective, it would be a simple and cost-effective intervention.
Dr. Kaplan is chief psychiatrist and Dr. Bodner is head of research at the mental health department of the medical corps of the Israel Defense Forces. Dr. Iancu is affiliated with the Zeriffin Mental Health Clinic of the medical corps and with the psychiatry division of Sheba Medical Center in Tel Hashomer. Address correspondence to Dr. Iancu at Psychiatry Service, Sheba Medical Center, Tel Hashomer, Israel (e-mail, email@example.com).